Tag Archives: NHS

Living loss

I got to know Joseph * over a number of months. He was first admitted to hospital in April, when his bed overlooked the garden with trees in bud. As Spring turned to Summer he was readmitted, and when Autumn came he watched the leaves change colour and fall. Each time he was admitted he spent more time in hospital and less time at home, and we worried more about whether this admission might be his last.

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Joseph had been diagnosed with Idiopathic Pulmonary Fibrosis, an incurable condition in which the lungs become progressively scarred, leading to breathlessness and functional decline. Like many patients with a chronic disease, he had opted for a coping strategy that focused on living, and trying to forget there was anything wrong. This meant that despite having symptoms for a number of years he had seldom seen a doctor, knew little about his disease or its’ likely trajectory, and had shared very little with his family. When we first met he resolutely refused to talk about deterioration, or dying. Our team respected this wish, focused on the here and now, and got him home. But we all had anxieties about how he and his family would cope as he declined, and about the difficulties of putting in place the help he was likely to need if he would not talk about the future. Over the coming months, with each admission he came to trust our team a little more, enough to have these conversations and to share his fears for himself and his family. We were privileged that he let us into his very private interior world, and we were able to help him adapt to some degree to his limitations, allowing him to focus a little more on the the things that gave his life hope and meaning.

What was apparent when talking to Joseph was that he was grieving. Grieving for the life he would not have and the things he would not do and see. Grieving for the loss of independence that he valued so highly. Grieving for the self he knew and recognised that was being replaced by an unfamiliar ill person. My Consultant used the term “living bereavement” to describe this response, which felt so right. It seemed to capture the denial, anger, bargaining, depression and finally acceptance that I witnessed in Joseph as he moved through a number of emotional responses to his illness.

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Living bereavement, living loss, or chronic sorrow, was originally described in relation to parents of children with severe disabilities. It describes a state and process through which an individual suffers repeated losses due a disparity between actual reality and an anticipated or desired reality. The term has now been used in reference to adults with a number of chronic diseases including diabetes, HIV, cancer, multiple sclerosis and parkinson’s disease. No studies have focused on patients with respiratory diseases, but the principles seem highly applicable. Losses are repeated, and can be physical, emotional or social. Common examples are: loss of bodily function; loss of relationships; loss of autonomous life; loss of identity; and loss of the life imagined.

Kelly (2008) explored the concept of living loss more deeply in patients with AIDS-associated dementia, particularly the way in which people live not only through, but ‘in’ loss. She described living loss as being a “social and constituted part of liminality.” Liminality was an unfamiliar word to me, but means ‘pertaining to a threshold’ and has been applied to rites of passage such as birth, marriage, and death, as well as so called ‘marginal identities’ related to race, gender or sexuality. In this context, people experiencing chronic sorrow are said to be in a liminal space between life and death, where there is the potential for transformative experiences as well as grief.

If we are to support patients to the best of our abilities, we must engage with their individual, personal experience of illness. Ahlstrom (2007) suggests that it is important to understand and acknowledge patients’ chronic sorrow in order to support adaptive coping strategies, and to inspire hope and courage. But perhaps even more than this, we need to engage with our own, personal responses to the losses we see and feel each day. The concept of living bereavement has been explored in healthcare workers themselves, in particular in carers of older adults in a continuing care setting. Holman (2008) described how staff “articulated a trajectory of loss which they witnessed and experienced as part of their everyday work… They called this living bereavement.” Areas of particular importance were: working with shocked residents; working with grieving relatives; working with anxious residents and relatives; working with residents’ degenerating bodies and minds; and working with dying residents.

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Living loss feels like a useful concept through which patients’ reactions to chronic illness can be understood. In addition, it provides a framework through which staff can understand their own emotions when watching their patients deteriorate and die. It has certainly helped me to reflect on my own reaction to Joseph and his family, to consider the emotional burden of this work, and to acknowledge the limitations of my influence on his grieving process.

Joseph died last month. He had the death that I think he wanted; in a place where he felt safe, with people he knew. His grieving has now ended, just as his family’s has begun.


 

If you are able to please consider supporting Breathing Matters, a charity specifically set up to fund research into IPF, and support patients and families living with the disease today.

Further reading:

*names changed to maintain patient confidentiality

Parallel lives

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I am immeasurably proud of the NHS: the most successful model of healthcare the world has ever seen. If anyone within my earshot suggests that privatisation would be a step forward they rapidly regret it. But even I sometimes get a wake up call: a stark reminder of the absolute necessity of the NHS, and the horror we may face if the political right’s dream of marketised healthcare is realised.

On a recent shift as the Medical Registrar I received a call from an A&E doctor who wished to discuss a patient who had suffered a stroke. I was surprised as all patients with strokes are channelled into the acute stroke pathway: assessed and treated by a dedicated team and admitted to a specialised unit for consideration of thrombolysis; specialist investigations; and early physio, speech and language therapy. However the A&E doctor explained the situation and I agreed to admit Maria*.

I sat by Maria’s bed in the Medical Assessment Unit, and listened as she told me her story. She was a UK citizen who had been living and working abroad. Whilst at home one day she had suddenly experienced weakness on the right side of her body and her speech had become slurred. She was rushed to hospital and diagnosed with a stroke. In the healthcare system she found herself in she was not assessed for and offered thrombolysis. She had to provide a payment method as soon as her initial assessment was complete and the bills began mounting from there. With every test and treatment she was offered she faced an impossible decision: could she afford what was being offered in monetary terms; and could she afford not to have it in health terms? This trade off had devastating effects. She did not have intensive physiotherapy, speech and language therapy. She did not have relevant investigations. She did not receive the best, evidence-based treatment.

By the time she received advice from the British consulate, and was helped to return to the UK for ongoing care, she was significantly disabled. On arrival to our hospital she had dense weakness with stiffening of the limbs leading to pain. She was wheelchair bound and struggled to get from chair to bed without assistance. Her speech remained impaired, making it difficult to communicate her wishes and needs. We admitted her to a medical bed, and the next day the specialist stroke team began working with her to regain as much function as they could. She has a long journey ahead.

If Maria had been at home in the NHS she would have had world class healthcare. She would have been assessed for thrombolysis. She would have had early physiotherapy, speech and language therapy and nutritional interventions. She would have been able to focus all her energy on her recovery and not worry about mounting debts. She would have embraced every test and treatment offered by her medical team, who themselves would have been focused entirely on her needs, not the financial state of their department. 

I watched in horror as the NHS was dismantled by stealth through the Health and Social Care Act. I wrote fervent letters, I shouted, I demonstrated, but to no avail. I often wondered why there was so much apathy from doctors of my generation. A recent article, by a Guddi Singh, who I went to medical school with, suggests some reasons including: a lack of understanding of health politics; being fooled by government rhetoric on the “choice” and “clinician-led” agenda; fear of rocking the boat, especially with a lack of organisational support (from the BMA and RCP who were noticeably silent about the proposed reforms); and a wish to just get on with the job. Doctors have a proud history of advocacy, but this side of our role does not get enough attention in modern medical school curricula.

We have only begun to see the effects of the devastating changes of the Act. As the NHS is systematically cut, ground down and sliced into pieces for private gain it will only get worse. I never want to work in a system in which the first person a patient in need sees is a cashier. I never want to work in a system in which patients trade financial ruin against health and wellbeing. I never want to make decisions about a patients’ care based on cost, rather than need. I never want to see another patient like Maria, and I never want her story repeated right here in the UK.

This can’t be the future. We can’t let it happen. I will be joining Guddi’s call to action and fighting tooth and nail to keep the NHS in the hands of the people, rather than the corporations – the friends of the political class. Markets are not the answer to questions around sustainable provision of high quality healthcare.

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Read more about the devastating destruction of the NHS, watch slices of public services being handed over to private companies, and see the impact of these changes on services you and your family may one day rely on.

Stop NHS privatisation.

Join us.

* names and other details changed to protect confidentiality

Lonely this Christmas

I love Christmas. But I occasionally find myself in a moment of loneliness in the midst of all the crowds and music and noise. When I see pictures of friends with their newborns, home just in time for Christmas; hear couples conspiring about the perfect present for each other; or catch the refrain of a song and am reminded that no-one is thinking “all I want for Christmas is you” the sparkle loses it’s shine. Being in the ever diminishing demographic of single 30-somethings can be lonely. But these moments are fleeting. I’m soon reminded of how much love surrounds me as my Mum calls to double check when my train is getting in, my brother texts to ask whether vegetarians eat gravy, and my friends email checking who is bringing the Gin at New Year. I know how lucky I am and how full of people my life is, and I was reminded of this on my last day of work before the Christmas holiday.

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Ron* was a patient I had previously met in clinic. He had severe COPD and lung cancer for which he’d opted not to have treatment. He was admitted the week before Christmas with breathlessness and we were treating him for an infective exacerbation of COPD. We were fully staffed and the team had the ward under control so there was time to do what I wish we could do more often: sit and chat. Ron was recovering slowly from his exacerbation but still feeling very breathless. He couldn’t walk more than a couple of steps before having to stop and rest. I suggested he would probably need to stay with us until after the weekend, and asked what his plans were for Christmas. He didn’t have any. No family. No friends. He, like so many other invisible members of our communities, would be having Christmas dinner for one. He had, over the years, lost those he cared for and been left alone. I said it was just as well he didn’t have plans as he may need to stay in hospital for Christmas this year. He agreed all too quickly.

I used to think it would be the most awful thing imaginable to be in hospital at Christmas. And for some this is true. But hospitals are bright, warm places, full of caring people. Every member of staff working this Christmas will do their best to spread some cheer, and give out an extra ounce of compassion to those they see. And for those people who have no-one; who might otherwise be alone, ill and afraid; hospital might be the best place to be.   

The NHS is there when no-one else is. It is part of, not only an ideal, but a reality of which we should me immensely proud: the welfare state. As a country we do not value our state services enough. They are not perfect, but they are wonderful.

I worry about the increasing pace of NHS privatisation. Who will be there for those who have no-one in a profit-driven system?

All I want for Christmas is the NHS to survive. Perhaps 2014 is the year to take action to make sure this happens…

Keep our NHS public

Can we find the spirit of ’45 in 2013?

Today marks a defining moment in the history of Britain, but looking around you wouldn’t believe it. Today, April 1st 2013, sees the The Health and Social Care Act (HSCA) come into force.

The death certificate of the NHS, issued by the National Health Action Party

The death certificate of the NHS, issued by the National Health Action Party

Some still believe that those opposed to the HSCA are over-dramatic, reactionary or naive. They will probably dismiss the National Health Action Party as extreme and publicity-seeking as it has issued a death certificate for the NHS, citing the cause of death as the HSCA 2013, with contributing causes including Thatcherism and the failure of New Labour. But it is difficult to see how anything but extreme statements and gestures can capture the attention of the public. Our generation is standing by as the NHS is quietly privatised and I for one am ashamed.

In 1948 the Attlee Labour government founded the NHS “the greatest gift a nation ever gave itself.” Since then it has been gradually eroded and dismantled. The King’s Fund’s infographic depressingly visualises various points of attack by multiple governments, starting with the creation of the internal market in 1989 when Margaret Thatcher signed the paper “Working for patients”. New Labour also have a lot to answer for; their PFI legacy crippling many Trusts today. But no previous government has actually tried to privatise the NHS, knowing that there would be a public outcry. Cameron and Clegg have privatised by stealth; clouding their agenda in a language of ‘choice’ ‘clinician power’ and ‘patient centredness,’ and ensuring that the reform documents were so long and complex that no-one, including most Ministers, understood them. The British media failed to report the warnings of individual doctors, nurses and other healthcare workers, and the demands of traditionally silent bodies such as the Royal College of Physicians to drop the Bill.

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The most worrying aspect of the reforms that come into force today are the Section 75 regulations, which state that all NHS services must be put out to competitive tender. This is not just allowing privatisation, it is mandating it. And all these profit-motivated private firms will be operating under the ‘brand’ of the NHS, so patients may not even know. Until the inevitable problems start to surface and it is too late.

Screen Shot 2013-04-01 at 18.34.44As I watched the welfare state being dismantled around me this week, I went to see Ken Loach’s film The Spirit of ’45 at The Barbican Cinema. It was a poignant reminder of a time full of hope and promise, and was a stark contrast to what I see today. In 1945 there seemed to be a collective vision of a society that could pull together for the benefit of all, with at least some people from all social classes believing that the State was a force for good, and that it had a responsibility to provide and protect the simple things most of us spend life striving for: purpose, dignity in work, family, safety, health, wellbeing, shelter, and comfort. 

Particularly powerful were interviews with doctors and patients who remembered a time before the NHS, when healthcare was only for the rich. In The Spirit of ’45 Dr Jacky Davis and Dr Jonathan Tomlinson, doctors working in the NHS today, talk eloquently about the doctor-patient relationship and about their fears about the future. Marketisation and competition change the relationship of doctors and patients to salesmen and consumers. I am no salesman and never will be.

The day after I saw The Spirit of ’45 I was on call in hospital. I was asked to speak to a patient about her medications before she went home, and quickly scanned through her notes before going to speak to her. She had had a tough few weeks, having been diagnosed with incurable (but treatable) lung cancer – only two weeks from having a chest x-ray revealing an unexpected abnormality to tissue diagnosis and treatment plan. This rapid diagnosis and treatment was an example of what happens every day in the NHS, and is a great example of the efficiency of our healthcare system, but it had left her little time to process the news. She was anxious about her medications prior to discharge so I spent a few minutes clarifying them and reassuring her.

As we ended the conversation she said thanks, and then hugged me tightly. It was nhs logoan unexpected level of physical contact and gratitude for a conversation that could only have lasted ten minutes. But it made me think. She wasn’t really thanking me. She was thanking the NHS: there for her from cradle to grave; at the most difficult time of her life; no questions asked; free at the point of need. Patients in the NHS are taken under the wing of an institution and cared for under an ideology. Today that ideology has suffered a fatal wound. Health is not a commodity, and markets will not make our NHS more efficient, more equitable or of higher quality.

Nye Bevan said “The NHS will last as long as there are folk left with the faith to fight for it”. As Owen Jones says “It is with huge regret that I must say that – however much faith we have – we did not fight to save it. The question now is – do we have enough faith to bring it back to life?”

As I look around the political landscape I fail to be inspired or energised by what I see. Attlee had vision, drive and a belief in the people.

I am looking for the Spirit of ’45 in 2013. Let me know if you find it.

Discharges in the dead of night

NHS Hospital discharges: thousands claimed to occur overnight

The news this week has been full of horror stories of patients being discharged from hospital in the dead of night. “Where is the compassion?” they cried, “How could they, the supposed caring profession?”  The stories began after The Times discovered, via Freedom of Information requests, that 100 NHS trusts sent 239,233 patients home last year between 11pm and 6am

The immediate response of the press was to paint a picture of an army of ambulance drivers booting out frail 90 year olds; dumping them at their front doors, alone in the dead of night. This dramatic depiction fuelled discussions on various forums and news programmes. The callers on Radio 4s “Any answers” actually made me turn the radio off.

My major concern is that this data was released without proper analysis. As usual in the reporting of science news, and particularly health-related news, the headlines were more important than the content. It took me two minutes to think of a list of possible contributing factors which may have led to these numbers of supposed patient discharges overnight:

  • Deaths are often coded as discharges. These may happen overnight.
  • Sometimes patients self-discharge, especially those admitted due to intoxication. On sobering up they may decide that at 5am they’d rather sleep off the rest of their hangover in their own bed. Good for them.
  • Many patients are offered the chance of discharge after a period of observation in a short-stay ward. Such patients are not really “admitted” in the traditional sense, merely held somewhere outside A+E due to the constraints of the 4hour rule, often awaiting test results.
  • Patients may leave the hospital hours before the discharge is “declared” by the ward. Sometimes this is due to the ward staff prioritising patient care over paperwork, and only getting around to logging the event later. Sometimes this is a more overt tactic to prevent more ward admissions when ward staff are under pressure. This may not be best practice, or good for patient flow, but is better than what has been imagined by reporters.

It is disappointing that those at The Times didn’t construct a similar list, and is part of a worrying trend of negative NHS stories despite high patient satisfaction. In my more cynical moments I wonder about influences on reporters and editors and links between media execs, politicians and those with interests in private healthcare.

“Patients should only be discharged when it’s clinically appropriate, safe and convenient for them and their families.” says Sir Bruce Keogh. Absolutely. I know no-one working in the NHS who does not “believe in the principles of holistic care – thinking about the patient as so much more than a bed filler and considering their lives outside the microcosm of the hospital.”

There may be a very small number of cases which fit the picture painted by The Times, and each of these is a failing of the system, which requires investigation and action. But please can we stop the media driven NHS-bashing? Those of us who work in public service endure long hours in difficult circumstances, but do so because we care. Nurses, doctors, occupational therapists, physiotherapists, pharmacists, discharge co-ordinators and matrons spend our working lives assessing patients to ensure that at the end of their medical investigations and treatment they are safe for home. When they are not we engage social services to put in place care to achieve a safe discharge. I worry that the profit motive, competition and privatisation will bring pressure to change this, but for now compassion remains at the heart of what we do, and no-one vulnerable and alone is going home at 3am on my watch.

BBC article: Overnight discharges from NHS hospitals to be examined

Sensible analysis by FullFact.org

An alternative day: how technology could enhance healthcare

Real day: 

I arrive at work, and quickly check my emails on my phone before I enter the signal black hole that is the hospital where I spend my working life. The SHO is not in yet, so I persuade the ward clerk to briefly give up one of only 3 functional computers on the ward and update the patient list with the details of the 2 new patients, whose names are scrawled onto the whiteboard. I skim through their notes, and cast my eyes over them to make sure nothing urgent is required. I leave a note for the SHO requesting her to arrange some tests, before I go to the secretaries’ office to hunt for a working dictaphone and a spare tape.

I arrive in outpatient clinic 15minutes before the first patient’s appointment and turn on the PC. I find the printed lists of the expected patients and pick up the first set of notes, searching through the years of mis-filing to find the referral letter. I finally find it in between a yellowing letter from Ophthalmology in 1994 and one from General Surgery in 1990 that I’m sure was typed on a typewriter.

This closely resembles my NHS clinic computer

By the time I have read the referral letter the computer has loaded up as far as the login screen. I enter my details, listen to it whir, and watch the egg timer turn over and over. I call in the patient and start the consultation as I wait for the screenprompts to enter separate passwords for the Radiology and Pathology applications. I take a history and perform a physical examination. I finally get access to laboratory tests, but have to filter the results in several different ways to get all the results I need. I can then finally look at some recent imaging, although I can’t compare this to old xrays as they have been archived and I don’t have time to ask the computer system to retrieve them from the data store as this has all taken quite a while and there are many patients waiting in the corridor. I fill in the patients details on multiple separate forms for additional blood tests, a CT Chest, and a further clinic appointment, and fill in a form that I keep to one side to fax to the GP later to advise on new medications. I want to check whether the new medication will interact with one of the patients’ other regular medications but the BNF that should be in the clinic room is missing. I can’t check on my phone as there is no wifi and no 3G signal and I don’t even try the desktop. I run out to the corridor and thankfully the nurse finds me a paper copy and I confirm the new drug is safe.. The patient leaves the room and I dictate a letter. As I rewind to correct a phrase I realise the tape is not working. Thankfully I have learned this lesson the hard way before so have a spare. I feel under pressure as I am already starting to fall behind schedule, grab the next set of notes and call the next patient in.

The morning continues like this, with the Radiology system completely crashing at one point, leaving me unable to review one patients’ latest scan. I therefore have to apologise to them and promise to call them later with the result.

After clinic I return the dictaphone and tape to the secretary and ask her to fax the necessary forms. I check the wards are OK, see 2 patients who can potentially go home and then grab a quick lunch. I get a phone call asking for a respiratory opinion on a ward patient, and in preparation for seeing them try to look up the recently published guidelines for pleural disease to confirm the latest management advice . The intranet is being difficult and is blocking Google, so I find a patch of signal between the store room and the toilets and resort to reading the guidelines in tiny text on my phone before going to see the patient.

We start the Consultant ward round, pushing the notes trolley around the bays, trying to find the drug charts and observations charts for each patient. We explain to Mrs Jones* that the Chest CT has confirmed what we suspected from the chest xray and that she has a mass. We suspect cancer. She struggles to understand what we’re talking about, but we’re unable to show her the scan as she is bedbound and the “Computer On Wheels” on the ward has not been charged so can’t move from the wall where it’s plugged in.

We continue round to Mrs Brown* who has a pleural effusion under investigation. She has had this before, a few months ago, and was investigated at our sister site. She can’t remember what they told her about the results, and we do not have the old notes as they have not arrived from the off site store. We see from the pathology system that some abnormal cells were seen, but without any old letters or notes it’s difficult to know what the clinicians who have been managing her since then have planned. We make a plan that will at least relieve her symptoms in the short term, and hope the notes will arrive before the weekend so we can integrate previous management into our plan.

Mr Low* is next. He has recovered well from his pneumonia but is less mobile and more dependant that he was prior to admission. He has been ready to go home for 2 days from a medical point of view but social services claim they never received the assessments we faxed and therefore have not put in place the package of care he needs to go home. We apologise to Mr Low for the delay and promise to do our best to get him home before the weekend. The sun is shining and he’d prefer a view of his garden to our car park.

After all the patients have been seen and everything documented, the SHO writes a request form for an urgent xray and walks two floors to drop off the form in the Radiology department. After searching 2 control rooms she finds a Radiographer who accepts the form and promises to make sure the xray is done that evening on call. She then returns to the ward, checks the blood tests and chest xrays that were pending, writes discharge summaries for the patients due to go home the next day, and updates the patient list. Since all these systems are separate it takes a while, but finally it’s done. The medical students she had promised to teach got bored waiting for her to complete all her paperwork and went home. She feels guilty for letting them down.

I have misplaced my patient list, but retrieve it from between 2 sets of notes in the trolley and take it with me to the office. I check the x-rays from the morning clinic and call the patient who’s scan I was unable to see. Thankfully it’s reassuring, so I do not have to break any bad news over the phone (what I was fearing all day). I check and sign the letters typed by the secretaries from a clinic earlier in the week and they are posted out. I write myself a to-do list for the next day, take off my stethoscope and head home, late again.

Imagined day:

I arrive at work. The SHO is not in yet so I grab my personal work iPad from its charging station and login. It opens immediately and I click the app for our patient list to see that the integrated system has automatically updated to feature our 2 new patients, whose names are highlighted in bold. I click on each of them in term and rapidly review their electronic admission notes, imaging and lab results. I have some time before clinic so introduce myself and chat to each of them, checking that each test required has been requested. The system shows an allocated slot for the echocardiogram, which I feedback to the patient. A CT has not yet been requested so I click on this, the system automatically inputting the patient’s details and latest blood results, and input my password to sign off the request. It appears as “pending” in the patient folder so the SHO will not waste time also requesting it if I don’t catch her before I head to clinic.

I arrive in outpatient clinic 15minutes before the first patient’s appointment and login. I pull up the clinic list, and due to the integrated system am able to directly link to all results and previous clinic letters. I read the first patients’ referral letter, check any recent results and review recent chest xrays. I compare to old xrays which is invaluable in this case, revealing a new shadow. I am thankful that old imaging is easily accessible since the hospital solved its data storage problems.

I have a lot of information before I call the patient is, allowing me to take extra time taking a history and performing a physical examination. There is time to explore the patients’ worries and answer questions. With a few clicks I request the additional blood tests, a CT Chest, and a further clinic appointment, and complete a template “urgent GP letter to advise on new medications”. This is automatically saved in my email outbox, with the relevant GP practices email address completed, for me to review and send later.  I click on the BNF app and quickly confirm that the new medication will not interact with one of the patients’ other regular medications. The patient leaves the room and I dictate a letter onto the voice recognition system. I notice a few typos but I elect to save the letter and review at the end of clinic before it is sent.

An example app, developed In London by North East London, North Central London and Essex Health Innovation and Education Cluster (NECLES HIEC) in partnership with Asthma UK, Queen Mary University London, Solar Software.

I am on time, and review the next patients’ recent letters and results before calling them in. I see that they have asthma and have started a new inhaler. I notice that they have been using an app to record their peak flow, which allows the patient, respiratory nurse and me to access the recorded data. I click to view the graph and feel well prepared to have some important discussions on treatment plans with the patient. The morning runs smoothly and I finish clinic with time to grab a coffee on my way up to the ward. I check my twitter feed in the lift and see a link to an article on new evidence on pulmonary fibrosis treatment that I save as a favourite to read later.

I  review and approve the letters from clinic and them and dock the iPad to charge. The letters automatically download and email themselves to the relevant GP practices. I check the wards are OK, see 2 patients who can potentially go home and then grab a quick lunch. While I eat I read the article I saved from my Twitter feed and think about a recent patient I saw that I must discuss with my Consultant. I get a phone call asking for a respiratory opinion on a ward patient, and in preparation for seeing them I look up the recently published guidelines for pleural disease to confirm the latest management advice. I have these guidelines saved as a link in my browser bookmarks so they’re easy to access.

We start the Consultant ward round, entering our comments onto the electronic notes system using our iPads. The drug charts are also electronic, allowing us to make changes at the same time that the nurses are logged in, dispensing drugs from the cupboard. The intelligent prescribing system prompts us to reduce the dose of a patients medication whilst they are on a particular antibiotic. We explain to Mrs Jones* that the Chest CT has confirmed what we suspected from the chest xray and that she has a mass. We suspect cancer. She struggles to understand what we’re talking about but since we’re able to show her the scan on the iPad she is better informed and is able to understand what will happen at the proposed lung biopsy.

We continue round to Mrs Brown* who has a pleural effusion under investigation. She has had this before, a year ago, and was investigated at our sister site. She can’t remember what they told her about the results, but we are able to pull up the old notes on the electronic system and can see what decisions were made before, and what the clinicians’ opinions were. We see from the pathology system that some abnormal cells were previously seen, but that after discussion with the patient and her family it was felt inappropriate to further investigate due to her frailty. We therefore make a plan that will relieve her symptoms and are able to start planning a supported discharge with community support.

Mr Low* is next. He has recovered well from his pneumonia but is less mobile and more dependant that he was prior to admission. He has been ready to go home for 2 days from a medical point of view, and since the relevant forms were sent to social services electronically they logged them on the day they were sent and immediately put in place the package of care he needs to go home. The hospital transport arrives as we are saying goodbye to him and he thanks us for getting him home to enjoy the sunshine in his garden, rather than forcing him to spend any longer staring out at our car park.

After all the patients have been seen and everything documented, the SHO clicks to request an urgent xray and calls the “hot room” where the on call Radiographer is keeping an eye on the urgent referral work stream. He looks at the request on his screen and promises to make sure the xray is done that evening on call. The SHO then checks the outstanding blood tests and chest xrays that were pending, completes the discharge summaries for the patients due to go home the next day (which have results of blood tests and scans auto-populated into them), and updates the patient list. She is then free to do the teaching she promised the medical students, and still finishes on time.

I check the x-rays from the morning clinic and pop in to see my consultant to discuss  a patient I saw earlier in the week. I bring up the new evidence I read at lunchtime and we discuss how this relates to this patient. We complete an assessment on my e-portfolio, and I add an entry to TILT, which I also post on Twitter.

I write myself a to-do list for the next day, take off my stethoscope and head home, on time.

Why I’m against the Health and Social Care Bill

“Are you political, then?” I was asked by a colleague yesterday who had noticed my “doctors say stop the bill” badge fixed proudly to my dress, beside my ID badge and stethoscope. Yes I am. But you don’t have to be “political” to be against this bill. You just have to want an NHS free at the point of need; an NHS in which clinicians are making decisions based solely on your clinical need; an NHS in which you can’t buy your way to the front of the queue; an NHS in which all money goes towards patient care, not shareholders. If you believe in equality and democracy you must make your voice heard, or forever regret it.
So here is a summary of why I, as an NHS doctor, citizen and patient am against the bill. At the end are things you can do to get your voice heard.

1. The government has failed to show that this massive, top-down, reorganisation of the NHS is “vital” as it claims. The NHS needs reform. No-one doubts this. But this bill is not the answer. There is no clear vision of what is trying to be achieved. I have not heard a single politician articulate the aims of the bill. In fact the changes that politicians, patients and doctors agree would be beneficial, including shifting decision-making powers to clinicians and streamlining patient pathways do not require legislation, and can be achieved without wholesale structural change. 

2. The government has no mandate for the destruction of the founding principles of the NHS. The changes proposed in the bill were not in the Conservative or Liberal Democrat manifesto. They were not in the coalition agreement. There has been no vote. The government has already started implementing parts of the bill before any House of Lords approval or Royal Assent. This premature and rapid implementation is already causing chaos on the ground, destabilising services. The government has also blocked demands to publish the risk register, and is ignoring the ruling of the information rights tribunal to publish it, underlining its total lack of respect for public opinion and democracy. The last time similar actions were taken was when there was a public demand for release of the legal advice the Blair government received about the legality of military action in Iraq, prior to the start of the conflict in 2003. We all remember how that turned out. The government has also ignored the e-petition and refused to hold a debate, despite gaining far more than the required 100,000 signatures. Pushing forward with the bill is undemocratic, autocratic and wrong.

3. Privatisation will increase under this bill. This is bad for patients. The record of private company involvement in the NHS is not good. PFI may have created a few sparkly hospitals but taxpayers will continue to pay extortionate amounts     for this privilege for years. Private companies only want to undertake simple, straightforward procedures in patients who are low risk. Not only does this leave out many older people with multiple co-morbidities, but when any patient has a procedure done privately, complications are dealt with in the NHS. The PIP implant disaster exposed the fact that private companies cannot be held accountable by the government; have no obligation to collect or supply accurate information about what they are doing; fiercely resist any duty of care to patients; and are more concerned with cost than quality. Look forward to more of this, not just in relation to cosmetic surgery. Private companies want all the profit, none of the risk and this bill hands it to them.

4. Those expected to implement the bill do not want it. The coalition have attempted to sell the bill to the public on the basis of clinician-led commissioning, giving power back to clinicians. Well, clinicians have made their opinion clear. Name a professional body and you can find a statement opposing the bill. Every day I am thankful that I am free to make decisions with patients based on clinical need, not cost. In all but a few specialist circumstances, such as new and expensive cancer drugs, cost never enters clinical discussions in the NHS. And we want it to stay that way. GPs, the clinicians who supposedly have the most to gain have made it clear that they do not have the time or skills required to deliver commissioning in the proposed model. They are first and foremost doctors, not managers.  Therefore the CCGs will outsource to private companies. More public money in the hands of shareholders, rather than patients.

Reorganisations and increased bureaucracy will cost the taxpayer heavily, at a time of austerity and cuts.

5. The bill will introduce more bureaucracy, which will cost, and will distract from care-giving. It will replace three layers of management in the NHS with at least six new ones. Many of the staff in primary care trusts have already left, returning to work for the commissioning groups and commissioning support services, often as consultants on a higher salary. This bureaucracy will not only slow down innovation and change, but will be hugely expensive. Management costs in the NHS are about 5% of the total budget. In the healthcare system in the US they are above 25%. It is a fallacy that markets drive efficiency. If the bill is passed, management consultants such as McKinsey and KPMG will make millions from the NHS budget “advising” clients on both sides of the purchaser/provider split, with additional contracts “advising” government and health regulators how to cope with the tangled web of contracts the new system would create.

Nye Bevan, founder of the NHS said “the NHS will survive as long as there are people left with the faith to fight for it”. I have faith. Do you?

Write to your MPadopt a peerwrite to your local paper, tell everyone you know, twitter your thoughts with #SaveOurNHS #dropthebill, directly tweet MPS eg @nick_clegg, @SWilliamsMP, @VinceCable #LDConf #lostvotes.

Other people have said all this and more, much more eloquently then me. Here are a few examples:

1. Clive Peedell, Clinical Oncologist and campaigner speaking at the Save Our NHS Rally

2. FalseEconomy.org.uk’s assessment of the effects of the bill – 5 facts

3. The Lancet’s summary, highlighting the failure of the bill to safeguard the core principles of universal care and the duties of the Secretary of State to uphold those principles. “The duty on the Secretary of State to provide or secure provision in accordance with the founding legislation of the 1946 Act must be restored if England is to have a national health service.” 

4. A patient who has found “gratitude, if not joy, in illness because we have a National Health Service, built on care.”

5. David Nicholl, a neurologist and human rights activist, explains why the NHS bill is beyond repair

6. Kailash Chand, a GP and the originator of the “Drop the health bill” e-petition

7. Analysis of Health and Social Care Bill published in BMJ, which concludes that it introduces a legal basis for charging and providing fewer health services (summary and link to full text)